2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation

Abstract

INTRODUCTION: Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis. CASE DESCRIPTION/METHODS: Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal. DISCUSSION: Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.